1. APPENDIX I

APPENDIX I



 

The terms conditions and limitations of the benefits described in 1.4 are contained in the written instruments listed from time to time in this Appendix I.

 
A. Medical and prescription drug funded by the trust and administered by Health Management Administrators, Inc. (“HMA”) in accordance with Everett School Employee Benefit Trust PPO Plan prepared by HMA, effective January 1, 2004.


 
A.B. Insured medical benefits provided through the following insurance contracts/policyies:
1. Group Medical Coverage Agreement, Group Number 0026100, between Group Health Cooperative and the Trust.
2. Employer Group Subscriber Agreement, Group Code 804139, between PacifiCare of Washington and the Trust.
 
B. Insured medical benefits provided by the following insurance carrier through Washington Education Association (the documents governing these benefits are the contracts between WEA and the below-listed insurance carrier):
1. Premera Blue Cross, Group Number 8000314-0001.
 
C. Insured dental benefits provided by the following insurance carriers through Washington Education Association (the documents governing these benefits are the contracts between WEA and the below-listed insurance carriers):
1. Washington Dental Service.
2. Willamette Dental Service.
 
D. Insured basic and voluntary term life and accidental death and dismemberment benefits provided through Metropolitan Life Insurance Company, Policy Number 74323-G.
 
E. Insured long term disability and employee assistance benefits provided through Standard Insurance Company, Policy Number 135033-B.
 
F. Voluntary insured short term disability benefits provided through Standard Insurance Company, Policy Number 135033-A.
 
G. Voluntary insured long term care insurance provided by UNUM Life Insurance Company of America. Under this policy UNUM insures the employees of Everett School District (the Sponsoring Organization) under the Select Group Insurance Trust Policy Number 292000.
 
H. Employee assistance benefits provided through Magellan Behavioral Health, Inc., Customer Number ESEB00-01.
 
I. Wellness program benefits offered pursuant to the Wellness Program described in Trust Policy 470 of the Everett School Employee Benefit Trust Operations Manual for Trustees.

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PROPOSED: April 30, 2012